Two of my patients are planning to become pregnant. One is taking paroxetine and the other lorazepam. We have discussed what to do when they become pregnant and have decided they should stop taking these drugs as soon as pregnancy is confirmed. Is this the right decision?

ANSWER

The decision to discontinue these drugs during pregnancy should be based on scientific evidence rather than "hearsay" that women should not take psychotropic medications during pregnancy. Recent epidemiologic studies have documented the relative safety of these drugs, so women should not feel compelled to stop taking them when they become pregnant. If, after receiving appropriate evidence-based information, a woman decides to stop taking the drugs, they should be gradually tapered off to avoid abrupt discontinuation syndrome.

Depression and anxiety disorders are common among women of
childbearing age, and these women are often prescribed antidepressants
and benzodiazepines. Although many of these drugs have been found not
to be teratogenic,1-4 fear of taking them during pregnancy
persists. For some reason, more fear appears to surround use of
psychotropic drugs than surrounds other types of medication, probably
because the illnesses for which they are prescribed even today still
carry a certain stigma. We were able to illustrate this in a recent
report on the safety of echinacea during pregnancy where 94% of the
women in the study perceived the herb to be safe for use during
pregnancy even though not a single study attested to its safety.5

Sudden discontinuation of antidepressants can cause patients to
experience discontinuation symptoms or re-emergence of the primary
psychiatric disorder.6 (The term "discontinuation" is
preferred over "withdrawal" because withdrawal implies addiction or
dependence.) Antidepressants have an extremely low risk of abuse; they
are not considered addictive agents.7 Symptoms of
discontinuation can include general somatic, gastrointestinal,
affective, and sleep disturbances that tend to occur abruptly within
days to weeks of stopping or reducing the dose. Re-emergence of
depression occurs more gradually.8 Reinstitution of
antidepressants mitigates the symptoms of discontinuation within a day,
but it might take several weeks for a beneficial effect on depression
to be felt.9

Although benzodiazepines can be abused, most patients do not abuse them.10
Benzodiazepine dependence is well documented, however, and is
characterized by loss of control over use of the drug, escalation of
the dose, and much time spent acquiring and using the drug or
recovering from its effects.11 Patients physically dependent
on benzodiazepines, whether they meet DSM-IV criteria for "abuse" or
"dependence," might experience symptoms following abrupt
discontinuation.12 Symptoms can last for weeks or months and
can occur when even therapeutic doses are stopped suddenly. Patients
report excessive anxiety, palpitations, insomnia, labile mood, and
restlessness and can suffer from perceptual disturbances, primarily of
vision and hearing. Seizures, psychosis, and delirium can also occur.13,14

We recently published a study documenting the adverse effects of
36 women who called the Motherisk Program after abruptly discontinuing
either antidepressants or benzodiazepines (28 had discontinued the
medications on the advice of their physicians). Before becoming
pregnant, these women had been functioning well with their depression
well controlled. They stopped the medication only because they feared
it would harm their babies. All the women suffered abrupt
discontinuation syndrome; 11 subsequently reported suicidal thoughts;
and four were later hospitalized. One of the remaining women had a
therapeutic abortion, and one substituted alcohol for a benzodiazepine.
After Motherisk's reassuring counseling, two thirds restarted their
medication within several days. All babies born to mothers who
restarted medication were normal and healthy.15 Physicians
should ensure that pregnant women with psychiatric disorders receive
evidence-based information that balances the benefits of treatment
against unproven adverse effects on unborn babies.

ABOUT MOTHERISK

Motherisk counselors talk to hundreds of women and their healthcare providers each day providing guidance, support and peace of mind. So if
you don't find the information you are looking for on this website, try calling one of our Helplines. Motherisk counselors are available Monday through Friday, from 9
a.m. to 5 p.m. EST.

OTHER MOTHERISK RESOURCES

The following corporations have provided financial support of $5,000 or more to Motherisk Programs and/or research since 2011: Beer Canada, Duchesnay, LCBO, Novartis, UCB and Shoppers Drug Mart. Funding from these organizations and their customers support Motherisk's research, helplines and other activities, but are not associated with the Motherisk Drug Testing Laboratory.

In addition, Dr. Gideon Koren, founding Director of Motherisk, acted as a consultant to Bayer, Novartis and Duchesnay during this time period.

* - "MOTHERISK - Treating the mother - Protecting the unborn" is an official mark of The Hospital for Sick Children. All rights reserved.

The information on this website is not intended as a substitute for the advice and care of your doctor or other health-care provider. Always
consult your doctor if you have any questions about exposures during pregnancy and before you take any medications.

The Hospital for Sick Children (SickKids) is a health-care, teaching and research centre
dedicated exclusively to
children;
affiliated with the University of Toronto. For general inquires please call: 416-813-1500.